Miller

ainterpersonal
Interpersonal
descriptive
MD, Wolfson
report
psychotherapy
Psychotherapy;
with
L, Frank
case(IPT)
vignettes
E,
Geriatric
Cornes
in a combined
Depression
C, Silberman
psychotherapy/medication
R, Ehrenpreis L, Zaltman
research
J, Malloy
protocol
J, Reynolds
with depressed
CF III:elders:
Using

Using Interpersonal Psychotherapy

(IPT) in a Combined Psychotherapy/
Medication Research Protocol With
Depressed Elders
A Descriptive Report With Case Vignettes

MARK D. MILLER, M.D.

LEE WOLFSON, M.ED.
ELLEN FRANK, PH.D.
CLEON CORNES, M.D.
REBECCA SILBERMAN, PH.D.
LIN EHRENPREIS, L.S.W.
JEAN ZALTMAN, L.S.W.
JULIE MALLOY, L.S.W.
CHARLES F. REYNOLDS III, M.D.

One hundred eighty subjects at least 60 years

of age with recurrent unipolar major
depression were recruited to participate in a
depression treatment protocol. All patients
received drug therapy with nortriptyline
(NT) and interpersonal psychotherapy (IPT)
with an experienced clinician. Acutely, 81%
of subjects showed a full response to combined
treatment. In the initial 127 subjects, the
most common problem areas in therapy were
role transition (41%), interpersonal disputes
(34.5%), and grief (23%). Case vignettes are
presented and discussed. The combination of
IPT and NT showed a powerful
antidepressant effect. IPT was readily
adaptable to the needs of depressed elders.
(The Journal of Psychotherapy Practice
and Research 1998; 7:47–55)
T he National Institutes of Health Consen-
sus Conference on Geriatric Depression
concluded that the current system of care de-
livery for depressed geriatric patients was “in-
adequate, fragmented, and passive” and
argued for more research endeavors to refine
promising psychosocial treatments, such as in-
terpersonal psychotherapy, for geriatric de-
pression.1
Although Sigmund Freud was pessimistic
about using psychoanalysis with the aged,2
many subsequent practitioners refuted that
view and proceeded to publish case descrip-
Received September 3, 1996; revised April 22, 1997;
accepted April 29, 1997. From the Mental Health Clinical
Research Center for the Study of Late-Life Mood Disor-
ders, Department of Psychiatry, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania. Address corre-
spondence to Dr. Miller, Western Psychiatric Institute
and Clinic, 3811 O’Hara Street, 7th Floor Bellefield Tow-
ers, Pittsburgh, PA 15213.
Copyright © 1998 American Psychiatric Press, Inc.

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

48
tions of geriatric cases with successful out-
comes. The literature prior to the 1980s is pri-
marily composed of such case reports, often
richly descriptive but limited to the experience
of single practitioners.3–14 Recently, research
efforts in psychotherapy have focused on the
use of manual-based psychotherapies such as
cognitive-behavioral therapy15 (CBT) or inter-
personal psychotherapy16 (IPT) in order to
standardize treatments by different practitio-
ners and allow for meaningful comparison be-
tween groups of patients receiving different
treatments.
In this article, we describe our collective
experience treating 180 depressed elderly pa-
tients over the past 7 years in a controlled treat-
ment trial, the Maintenance Therapies in
Late-Life Depression (MTLLD) study. We be-
gin with a brief background of the develop-
ment of IPT and a description of the protocol
within which it was used. Preliminary cross-
sectional data are presented along with case
vignettes to illustrate each IPT problem area.
Interpersonal psychotherapy of depres-
sion was developed about 25 years ago by Ger-
ald Klerman, Myrna Weissman, and their
colleagues in the New Haven–Boston Collabo-
rative Depression Research Project. It was
described by the authors as “a focused, short-
term, time-limited therapy that emphasizes
the current interpersonal relations of the de-
pressed patient” (p. 5).16 The focus of IPT is
jointly agreed upon by patient and clinician
and is broadly contained in one of four prob-
lem areas: abnormal grief, role transition, role
dispute, or interpersonal deficit. The tech-
niques of IPT are based on a long tradition of
interpersonal psychotherapy, primarily devel-
oped in the Baltimore-Washington area, and
on many empirical studies related to attach-
ment bonds and significant life events.17
Karasu18 has published a comparison of IPT
with other psychotherapies for depression, de-
scribing the major features, advantages, and
limitations of the psychodynamic, cognitive,
and interpersonal approaches.
The rationale for using IPT was initially
described in a treatment manual and was
VOLUME 7 • NUMBER 1 • WINTER 1998
IPT FOR DEPRESSED ELDERLY PATIENTS
subsequently published as a textbook,16 which
has been used to train clinicians in a variety
of clinical and research settings. Over the
years, IPT has been modified for use with
specific populations, such as those with re-
current depression or depression in late life
or adolescence.19 I P T has been demon-
strated empirically to be an effective form of
treatment for acute and maintenance treat-
ment of adults ages 18 to 60.15,20
M E T H O D S
Description of the MTLLD Study
The Maintenance Therapies in Late-Life
Depression study was conceived to attempt to
reduce the high recurrence rate observed in
geriatric depression by comparing the efficacy
of the antidepressant nortriptyline (NT) with
interpersonal psychotherapy and their combi-
nation as maintenance treatments under
placebo-controlled, double-blind, random-
assignment conditions. I PT was chosen
because it was anticipated to be readily
adaptable to the problems facing elders, par-
ticularly grief and role transitions. Further-
more, IPT is a manual-based psychotherapy
that can be standardized and verified.
The MTLLD study enrolls elderly indi-
viduals with a history of recurrent depression
during a current episode of major depres-
sion. Patients were excluded if they were bi-
polar, dementing, psychotic, diagnosed with
neurodegenerative disease, or medically un-
able to be tried on NT or to travel for weekly
visits. Since the goal of the study is to com-
pare the efficacy of maintenance treatment,
the first task is to maximally treat the current
episode. All patients in the acute phase of the
study therefore receive combined IPT and
NT. All patients are seen weekly for 50 min-
utes of IPT for a minimum of 12 sessions.
After achieving stable remission for 16
weeks, patients are then randomized for 3
years of maintenance follow-up on either NT
or placebo in combination with either monthly
IPT or a 15-minute medication check. For a
MILLER ET AL.
more detailed description of the MTLLD pro-
tocol, see Reynolds et al.21 A report on the dif-
ferential efficacy of these maintenance
assignments will be available once the ongoing
study is complete.
Teaching IPT to
Protocol Psychotherapists
Teaching of the principles of IPT was car-
ried out under the direction of senior clini-
cians, all of whom were highly experienced in
its use from previous studies through direct col-
laboration with the developers of IPT. All
therapists completed a 6-month didactic
course (11⁄2 hours per week) on the principles
of IPT, including videotaped case vignettes.
Each therapist was assigned two pilot cases,
working with an individual supervisor on a
weekly basis as well as alternately presenting
videotapes for weekly group discussion and
supervision. As the study progressed, the
weekly case conference also served as an op-
portunity for ad hoc validation of the most
appropriate focus of therapy. The pilot expe-
rience of Sholomskas et al.22 recommended
that therapists maintain an active stance, that
they be prepared to help patients with practical
problems such as finances or transportation,
and that they maintain an awareness that op-
tions for change may be limited among elderly
patients.
We expected our elderly subjects as a
group to be struggling more frequently than
younger subjects with issues of grief and loss
and with role transitions such as retirement
and relocation. Regarding role disputes, we
tried to remain cognizant of the writings of
Sholomskas and colleagues, who warned
that elderly individuals may see themselves
as having fewer options to make changes in
role disputes than younger persons. Finally,
we expected to find a disproportionate num-
ber of subjects in an elderly cohort confront-
ing issues of aging, illness, and the perception
of impending death.
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
49
R E S U L T S
Introducing IPT to Elderly Subjects
Many of our geriatric patients had little
experience or understanding of psychother-
apy prior to enrolling in the MTLLD study.
They voiced their willingness to do anything
to feel better but did not always come asking
for psychotherapy in particular. Because IPT
was a requirement of protocol participation,
every effort was made to educate patients
about the process and potential benefits of IPT.
The vast majority of patients were able to learn
and use the psychoeducational aspects of IPT
and to use the time in therapy fruitfully.
The majority of patients worked very hard
in therapy and reported reviewing sessions on
their own and sometimes keeping notes. They
voiced appreciation for the opportunity to
have the psychotherapy sessions, since they
often had no other confidant.
Overall, MTLLD therapists found fewer dif-
ferences in applying IPT to elderly patients than
anticipated. There was a range of psychological
mindedness among our patients that was very
similar to our experience with younger popula-
tions. On the whole, carrying out IPT was not
more difficult with elders. A few patients could
not tolerate full 50-minute sessions when acutely
depressed, but most were easily engaged and
very reliable about keeping appointments. Be-
cause few patients were still working, schedules
were flexible and time was less restricted than
with younger patients.
Dependency issues did arise infrequently
when the maintenance phase approached and
patients anticipated a 50% chance of no longer
receiving psychotherapy. We were careful to
handle termination according to the IPT prin-
ciples of beginning discussion of these issues
well in advance of transition times and by con-
fronting them openly.
Cross-Sectional Data
Thus far, the combined use of IPT and NT
has been shown to be a powerful treatment for
50
depression in elderly subjects, with a full re-
sponse rate of 81% (defined as a score ≤ 10 for
3 consecutive weeks on the Hamilton Rating
Scale for Depression23 [Ham-D]). Mean
pre/post Ham-D scores among responders
were 21.9 (SD = 4.2) and 4.9 (SD = 2.8), re-
spectively. Detailed reports of other prelimi-
nary outcome variables have been published
elsewhere.21,24,25
The four major problem areas that serve
as foci in IPT are 1) abnormal grief, 2) role
transitions, 3) role disputes, and 4) interper-
sonal deficits. A detailed analysis of the first
127 patients showed a primary psychotherapy
focus on role transition in 41%; a focus on grief
in 23%; a focus on role disputes in 34.5%; and
a focus on interpersonal deficits in 2 subjects.
The role transitions that were associated with
depression in our elderly patients, in descend-
ing rank order of frequency, are aging issues,
retirement, declining health, “empty nest,”
loneliness, widowhood, relocation, ill signifi-
cant other, marital change, work-related role
transition, and dating. A secondary focus of
role transition was identified in 57% of patients
(in 41% of those with grief as a primary focus
and in 32% of those with interpersonal dispute
as a primary focus). The breakdown of losses
precipitating grief, in rank order, was as fol-
lows: spouse, adult child, parent, sibling, close
friend, nephew, and multiple family members.
The problematic relationship in the 44 subjects
with a primary focus on role disputes was most
frequently with a spouse, followed by inter-
action with children, multiple family mem-
bers, and, in one case each, a sibling and a close
friend. For a detailed account of clinical and
demographic correlates of IPT foci, see Wolf-
son et al.23
Case Vignettes
Role transition, illustrated in the following
vignette, was the most frequent problem we
encountered. As the role transition crisis
abated in the early phase of treatment, the fo-
cus of IPT changed to role dispute.
VOLUME 7 • NUMBER 1 • WINTER 1998
IPT FOR DEPRESSED ELDERLY PATIENTS
The tasks of the IPT therapist in a role
transition are to 1) elucidate the lost role, 2)
facilitate the expression of emotion surround-
ing it, 3) encourage the development of social
skills suitable for the new role, and 4) seek so-
cial supports to help maintain the new role.
Case 1: Role Transition/Role Dispute. Mr.
A., a 61-year-old white, married professional, pre-
sented in his third episode of major depression.
He reported previously seeing a psychiatrist for
“advice” during a midlife crisis but not finding it
very helpful.
Mr. A. described how his professional prac-
tice partner had recently retired, leaving him with
an office he could not afford. Gradually, a picture
came into focus of a man with deep ambivalence
about his chosen profession and a pattern of fi-
nancial negligence in paying debts and collecting
fees that was nearly bankrupting him. Mr. A. ex-
plicitly stated that his ambivalence toward start-
ing again with another practice versus taking up
other employment or choosing retirement was
particularly depressing to him. A focus on role
transition seemed most appropriate at the outset.
After several sessions exploring various op-
tions and providing him an opportunity to venti-
late his feelings about his work-related
ambivalence, Mr. A. finally decided to invest in a
new office, found a young partner, and opened a
new practice. His goal was to retire in 5 years.
His depression gradually improved over the ensu-
ing 3 months.
During his IPT treatment, Mr. A.’s wife was
diagnosed with cancer. She was successfully
treated with chemotherapy and achieved a rapid
remission, but her tolerance for her husband’s be-
havior was diminishing. She became more con-
frontational regarding his pattern of “forgetting”
to fulfill his responsibilities, which now seemed
more pronounced since her treatment had left
her greatly weakened and more of the day-to-day
responsibility of running their affairs fell into Mr.
A.’s hands. She once telephoned out of despera-
tion, complaining about his behavior in light of
their dire financial circumstances. Gradually, a
pattern of passive deferral or passive aggression
toward his wife became clear, and a shift in the fo-
cus of IPT to role dispute seemed appropriate. A
few conjoint sessions were deemed necessary to
deal with the crisis of his wife’s cancer diagnosis.
During these sessions, Mrs. A.’s accusations of a
MILLER ET AL.
long-standing pattern of passive aggressive behav-
ior and convenient forgetfulness were not denied
by Mr. A. Their relationship had developed a ho-
meostasis that rested upon Mrs. A.’s ability to con-
tinually rescue her husband when his negligence
caught up with him. The inclusion of his wife in
these conjoint sessions helped to reveal more
fully the patient’s lifelong character pathology.
His “forgetfulness” became so problematic that
Mr. A. and his wife requested neuropsychological
testing because she was afraid he might be show-
ing early signs of dementia. The test results were
negative for significant cognitive impairment.
Since IPT does not seek to change personal-
ity structure per se, his IPT therapist continued to
focus in very practical ways on the day-to-day
tasks as they related to role disputes with his wife.
On review with Mr. A. of the list of his day-to-
day responsibilities, he appeared to be more forth-
coming about his long-standing pattern of
avoiding responsibilities. With continued review
of these issues, Mr. A. began to take more respon-
sibility for the running of the household. He be-
came more attentive to his wife’s needs and more
honest with her about what he was willing and
able to do. Mr. A.’s wife confirmed that he
seemed better at “hearing her” and she now felt
she was receiving more of the support she sorely
needed to cope with her cancer.
The vignette of Mr. A. illustrates a case of
shifting focus from role transition (work tran-
sition) to role dispute (marital conflict). The
long-standing character traits of passivity and
passive aggression were acknowledged by the
IPT therapist but addressed only through per-
sistent reevaluation of here-and-now themes.
The crisis of his wife’s diagnosis of cancer
caused Mr. A. to more fully confront his long-
standing, maladaptive behavior patterns. His
IPT therapist was able to help him see the re-
lationship of these behaviors to the role dispute
with his wife and to seek alternative strategies
that were more appropriate.
Role disputes that were ameliorated by work,
child care, or independent activity often
proved to be more difficult when one spouse
became ill or dependent or if retirement or
children leaving home required a couple to
spend more time together, as the following
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
51
case vignette illustrates.
Case 2: Role Transition/Role Dispute/Abnor-
mal Grief. Mrs. B., a white, married 64-year-
old, presented in her fourth episode of major
depression, never having had any previous expe-
rience in psychotherapy. She had recently retired
from her position as a health care provider. She
was extremely anxious and guarded at the onset
of therapy and reported an almost complete re-
mission of depressive symptoms in the first week.
The clinical staff was intuitively skeptical of this
“flight into health” and was able to convince her
to stay in the program. Within several weeks, her
symptoms returned and her Ham-D score was as
high as it had been initially. She was extremely
anxious and had a difficult time engaging actively
in therapy. After a cautious start, the educational
component of IPT began to pay off and she be-
gan to engage more actively. Gradually, she be-
gan talking about her difficulties in adjusting to
retirement. These included difficulties in time
management, learning to manage money, and set-
ting boundaries on her availability for baby-sit-
ting her grandchildren. The first 5 to 8 sessions
focused on these role transition issues.
Once Mrs. B. began to feel somewhat better
and a therapeutic bond formed, she began to re-
veal deep-seated resentments toward her hus-
band. She requested that we shift our focus away
from her problems with retirement and onto her
role disputes with her husband. Each situation
that Mrs. B. brought to therapy manifested an un-
derlying imbalance of power and control. Mrs. B.
described her husband as a benign dictator. Her
IPT therapist explored specific instances of the
power imbalances she described and her usual re-
sponse of failing to ask for what she wanted be-
cause she “knew” he would become upset if she
disagreed with him. After exploring alternative
strategies and the potential consequences of
greater assertiveness, Mrs. B. vowed to attempt to
speak up more and be more clear about her
needs. The interpersonal disputes worsened with
these initial attempts, as did her own internal dis-
sonance. With continued confrontation and clari-
fication of this pattern, Mrs. B. recognized her
own responsibility in allowing her husband to
“rule the roost” and the great difficulty she had in
asserting herself. With the continuing support of
her IPT therapist, Mrs. B. made persistent at-
tempts to assert herself more clearly and was
both surprised and delighted to find her husband
52
more willing than she had imagined to share in
decision making. With practice, she eventually
became more comfortable with her newly ac-
quired role. Through her work in IPT, Mrs. B.
was able to learn to be more aware of her role in
her marital discord and to accept more personal
responsibility for their joint problems. The net ef-
fect of these efforts led to improved marital com-
munication.
As the interpersonal dispute with her hus-
band improved, Mrs. B. revealed another dimen-
sion of her interpersonal life that related to her
depression. Her sister, who was her primary confi-
dant, had died several years earlier, and Mrs. B.
felt that she had never properly grieved for her.
This was due, in part, to complex dynamics in
her family, such as family secrets that only she
and her sister shared, as well as Mrs. B.’s unwill-
ingness to allow herself to “let go” and really
mourn, since her primary role in the family had
always been to take care of others. With gentle en-
couragement Mrs. B. was able to step out of her
role as caregiver and to express a great deal of
her grief and pain. She chose to share some of
the family “secrets” that had played a role in her
buried grief for her sister. Her father was much
older than her mother and developed Parkinson’s
disease while many of the children were still
small. Since her father was unable to continue
working, her parents took in boarders to generate
income. Her revelation of the family secret that
her mother had several love affairs with her male
boarders was followed by extreme self-doubt and
worry that she was being disloyal to her family
for talking about this “secret.”
Mrs. B. spoke of her difficulty trusting the
confidence of her sister, who also knew of the “se-
cret.” Mrs. B. had wanted many times to discuss
it with her sister but had never done so. The issue
of trust was explored at length, and Mrs. B. ex-
pressed her appreciation for having the opportu-
nity to discuss these issues in a “safe” forum
where there were no ramifications in her per-
sonal life. The issues of trust, shame, embarrass-
ment, and loyalty were each explored in turn,
since they were key to unlocking her buried, in-
complete grieving for her late sister.
Her IPT therapist was able to tie Mrs. B.’s
feelings surrounding grief for her sister to her cur-
rent situation (and thus return the focus to the
present) by helping her to explore ways in which
she might become more flexible in her roles with
important people in her life now and learn to ask
VOLUME 7 • NUMBER 1 • WINTER 1998
IPT FOR DEPRESSED ELDERLY PATIENTS
for support from others when she needed it.
The role of the IPT therapist is to explore
problem interpersonal relationships and
search for ways in which they might be han-
dled better. Mrs. B.’s IPT therapist recognized
her problem trusting others and encouraged
her to learn to ask for more from others within
her significant relationships.
Early in treatment, this patient demon-
strated the “flight into health” phenomenon
because of her anxiety about “opening up.”
Her IPT therapist, through patient and persist-
ent psychoeducational efforts, convinced her
of the safety of sharing her interpersonal diffi-
culties as she saw them. Mrs. B.’s initial com-
plaints indicated a role transition focus
(retirement), followed by psychotherapeutic
work centered on her role disputes in her mar-
riage. After progress handling the first two
problems, a third, more briefly explored focus
on unresolved grief was made possible by her
bolstered confidence that she could trust her
therapist with her most deeply held secrets.
Issues arising from old traumas might be
expected to surface more often in elderly pa-
tients because they have more years of accu-
mulated experience. IPT does not set out to
elucidate early life experiences or uncover
traumas per se, as one might in psychodynamic
or psychoanalytic therapies; however, when
patients bring them up, it is appropriate in IPT
to encourage the ventilation of feelings around
the old trauma. Mrs. B. clearly needed to share
the long-held family secret that was connected
to her unresolved grief for her sister. After al-
lowing her to express her feelings about the
matter, her IPT therapist gently brought her
back to the present and connected the issue to
her current problems by posing questions to
her about how she might learn to ask for more
support and understanding from others in-
stead of continuing a pattern of silent suffering.
We expected to encounter difficulty coping
with grief and loss in our elderly subjects and
frequently did so. We have previously written
at length about our experiences using IPT for
grief in elders.26 The following vignette illus-
MILLER ET AL.
trates one presentation of abnormal grief.
Case 3: Abnormal Grief/Role Dispute. Mr.
C., a white, single 64-year-old, reported a history
of persistent depressive symptoms for 3 years
prior to his admission to the MTLLD study. Mr.
C. had never married but was very close to his
siblings and their families. Mr. C. was a health
care professional and, as such, regularly assumed
the role of caregiver with his entire family’s medi-
cal problems. He was particularly close to his 10
nephews, with whom he especially enjoyed play-
ing golf.
Four years prior to his presenting for help,
one of his nephews died of leukemia at age 37. A
month afterward, another nephew, also in his thir-
ties, died suddenly from a cerebral aneurysm. In
1988 one of his brothers died, and a year later a
second brother died. Shortly after that, one of his
great-nephews (age 25), died in a car accident.
Mr. C. said, “I have been grieving for the last
three years.” To make matters worse, as a result
of prostate cancer treatment, colon resection, and
recent carpal tunnel surgery, he himself could not
play golf for an entire season.
The IPT focus, abnormal grief, was compli-
cated by several factors. In addition to being dis-
tressed by his own limiting illnesses, Mr. C. was
resentful of being continually thrust into the role
of liaison with various health care providers who
were caring for his ill relatives, a role he found to
be extremely stressful but to which he could
never say no. Additionally, although other family
members, especially the parents and spouses of
the deceased, received support and acknowl-
edgment of their losses, no one seemed to recog-
nize the depth of his losses. He was “only the
uncle,” although it became clear that he shared a
special bond with his nephews.
His IPT therapist offered a safe, supportive
forum to express all of his feelings of sadness for
his lost relatives, as well as his negative feelings
that his grief was not being legitimized by other
family members and that he was being taken for
granted as a health care liaison despite his own
medical problems and restrictions. With contin-
ued confrontation of his role in allowing the
status quo to remain, he expressed a willingness
to be more assertive in declining some of the ex-
pected obligations he no longer felt he could
fulfill. The self-perception that he had to “give
more” as “only an uncle” to feel worthy of inclu-
sion in the family was challenged, resulting in the
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
53
acknowledgment that his own problems were just
as deserving of family attention and support.
By first acknowledging the legitimacy of
his grief, IPT offered Mr. C. the opportunity
to openly grieve, to talk about how he experi-
enced his nephews’ deaths not only as the
“family nurse,” but also as their beloved uncle.
He also learned that he could relieve his re-
sentment at being overburdened by his fam-
ily’s medical needs by being more assertive in
his expectations that he be included as a full-
fledged family member complete with his own
problems, not just “the uncle.”
D I S C U S S I O N
In our experience, IPT in combination with
nortriptyline shows a high degree of utility with
depressed geriatric patients. We were im-
pressed with the ability of our patients as a
group to learn from the psychoeducational
components of IPT, to become working part-
ners in psychotherapy, often without prior
experience, and to use IPT to modify interper-
sonal problems.
A shift of focus during IPT occurred in
57% of our subjects. In the case vignettes, Mr.
A.’s job-related role transition and his wife’s
cancer diagnosis forced a confrontation with
long-standing maladaptive behavior in his
marital relationship. Mrs. B. revealed her long-
standing resentments toward her husband only
after exploring her difficulties adjusting to re-
tirement. Mr. C. struggled with the grief of mul-
tiple losses through death before confronting
his resentment toward various family mem-
bers who assumed he would be their health
care liaison. Perhaps a more crisis-oriented
therapy with limited sessions would not have
allowed for these secondary role disputes to
emerge; however, in our view the secondary
focus on role disputes is often the most impor-
tant focus that is “saved for last”after more
temporary adjustments in coping have been
made and after patients have developed the
required rapport to approach more worrisome
or deep-seated problems in their relationships.
In other words, role transitions are easier to
54
handle if important relationships are viewed
as working well, and vice versa.
Regarding spousal role disputes, perhaps
we are seeing an age cohort effect, since di-
vorce would have been more frowned upon in
the earlier years of these couples’ marriages
than in recent times. Couples with severe mari-
tal strains may have found ways to cope, how-
ever tenuous, only to find their tried and true
strategies were failing as the stresses of late life
accumulated. One-third of the patients with a
primary focus of role dispute showed a secon-
dary focus of role transition. Perhaps an un-
avoidable role transition precipitated a shift of
a tenuously balanced relationship into one
with a serious role dispute. It is not difficult to
imagine the stresses of a new medical illness
or the approach of retirement precipitating
more disputes between spouses.
The clinical impressions of the 5 partici-
pating IPT psychotherapists treating these 180
patients over the past 7 years were that IPT
required no major modification and was no
more difficult to carry out than IPT with
younger patients. There were certainly in-
stances when financial, legal, medical, trans-
portation, or housing problems arose and
required exploration and sometimes practical
recommendations for appropriate assistance.
These instances were seen somewhat more
frequently than with younger patients, but they
did not significantly interrupt or overshadow
R E F E R E N C E S
1. NIH Consensus Development Panel on Depression in
Late Life: Diagnosis and treatment of depression in
late life. JAMA 1992; 268:1018–1024
2. Freud S: On psychotherapy (1905), in The Standard
Edition of the Complete Psychological Works of Sig-
mund Freud, vol 7, translated and edited by Strachey
J. London, Hogarth Press, 1953, pp 255–268
3. Lazarus L: Clinical Approaches to Psychotherapy
With the Elderly. Washington DC, American Psychi-
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VOLUME 7 • NUMBER 1 • WINTER 1998
IPT FOR DEPRESSED ELDERLY PATIENTS
the focal work in IPT. The reader should bear
in mind that elderly subjects with significant
memory loss or dementia, who would be ex-
pected to require even more assistance, were
excluded from the protocol.
In preparing to work with depressed el-
derly patients, we found a review of principles
of gerontology highly useful to familiarize our-
selves with and be able to anticipate common
problems and needs of elderly patients in gen-
eral. A background course in gerontology or a
year or more of experience working with eld-
ers is highly recommended for clinicians inter-
ested in applying IPT to elderly patients.
Although the use of nortriptyline with
IPT, in our experience, has been a powerful
antidepressant combination for elders with re-
current depression, we cannot comment on the
differential effects of these two treatments as
acute treatments. Report of the comparative
efficacy of IPT, nortriptyline, and their com-
bination as maintenance treatments will follow
upon completion of the MTLLD protocol.
This work was supported in part by National Insti-
tute of Mental Health Grants MH43832 (C.F.R.
III, Principal Investigator), MH37869, MH00295,
MH30915, and MH52247, and by a Young Inves-
tigator Award to M.D.M. from the National Asso-
ciation for Research in Schizophrenia and Affective
Disorders.
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